TMS teams commonly track progress with a short questionnaire, most often the PHQ-9, repeated every week or so during the course. You answer nine questions about the past two weeks, the answers add up to a score from 0 to 27, and the change in that score over time shows whether you are responding. A drop of half or more from your starting score is usually called a "response"; a score low enough to count as minimal symptoms is called "remission".
Scores are not the whole story, though. Pairing them with a simple personal log, and knowing what to report straight away, gives you and your psychiatrist a much clearer picture than either alone.
Why measure at all? Measurement-based care
Depression distorts memory for how you felt. On a bad day, it can seem as though nothing has changed in weeks, even when it has. Regular scores give an outside reference point.
There is evidence that measuring changes care, not just records it. In a randomized trial of 120 outpatients with moderate to severe depression, treatment decisions guided by rating scales led to higher response (86.9% vs 62.7%) and remission (73.8% vs 28.8%) than usual clinician judgment. That trial was about antidepressant medication, not TMS, but the principle carries over: numbers prompt timely decisions.
The PHQ-9, question by question
The PHQ-9 scores each of the nine symptoms of major depression from 0 ("not at all") to 3 ("nearly every day") over the last two weeks. It was validated in 6,000 primary care and obstetrics-gynecology patients, and a score of 10 or more identified major depression with 88% sensitivity and 88% specificity.
| PHQ-9 total | Severity band |
|---|---|
| 0 to 4 | Minimal |
| 5 to 9 | Mild |
| 10 to 14 | Moderate |
| 15 to 19 | Moderately severe |
| 20 to 27 | Severe |
These bands come from the original study, which set scores of 5, 10, 15 and 20 as the thresholds for mild, moderate, moderately severe and severe depression.
The ninth question asks about "thoughts that you would be better off dead or of hurting yourself in some way", and it counts if present at all. Answer it honestly. A positive answer does not automatically end a TMS course; it tells the team to check in with you, which is exactly what you want. If you are thinking about suicide or are in crisis, call or text 988 (the 988 Suicide & Crisis Lifeline) or go to the nearest emergency room.
The scales used in research
When you read about TMS studies, you will see clinician-rated scales rather than the PHQ-9. Knowing the names helps you read results sensibly.
| Scale | Who scores it | Example remission cut-off in TMS studies |
|---|---|---|
| PHQ-9 | You | Below 5 |
| HAM-D (Hamilton), 21-item version | Trained clinician | Below 10, in the deep TMS pivotal trial |
| MADRS (Montgomery-Åsberg) | Trained clinician | 10 or below, in the SNT trial |
| BDI-II and IDS-SR | You | BDI-II 9 or below, in a retreatment study |
The same people can look different on different scales. In one real-world study of 307 TMS patients, clinician-rated response was 58.0%, while self-reported response ranged from 56.4% on the PHQ-9 to 41.5% on the IDS-SR. That is one reason to compare your scores with your own earlier scores on the same scale, not with a percentage you read online. The physician's guide explains how response and remission are defined in more depth.
Response, remission and "meaningful improvement"
- Response usually means at least a 50% drop from your baseline score. From a PHQ-9 of 20, that would be 10 or lower.
- Remission means symptoms low enough to count as minimal, such as a PHQ-9 below 5.
- Meaningful improvement is a smaller step. A large adolescent and young adult registry used a drop of 6 or more PHQ-9 points as its marker.
Partial improvement still counts. Many people move from severe to moderate before they move further, and that shift can make daily life noticeably easier.
When to expect change, and what early scores mean
Change is rarely linear. Expert consensus advises that a standard course of 20 to 30 sessions over about 6 weeks will very likely be needed to match trial results. In a large clinic series that combined TMS with therapy, improvement by session 10 was strongly predictive of response at the end. In a study of people having a second course, response came earlier, at a median of session 12 compared with 16 the first time on the PHQ-9, and 13.5 compared with 22.5 on a second scale, the BDI-II.
So an early drop is encouraging, and a flat score at week two is not a verdict. Read when TMS starts working and a typical TMS course, week by week for what each stage tends to look like.
Keeping a personal mood log
A questionnaire every week misses the texture of daily life. A one-minute daily log fills that gap. Keep it on paper or in your phone's notes, and record the same few items each day:
- Mood on a scale from zero to ten.
- Sleep: roughly how many hours, and whether it felt restful.
- Energy and motivation: did you start something you had been avoiding?
- One concrete thing you did: a walk, a call, a meal you cooked.
- Side effects: headache, scalp soreness, anything new.
- Anything unusual: a stressful event, alcohol, a missed dose, a bad night.
Look for function as well as feeling. Often the first changes are practical, such as answering emails, showering without effort or cooking again, before mood itself feels lighter. Others, including a partner or close friend, may notice these first; see supporting a loved one through TMS for how they can help. Therapists can use the same log, as described in TMS and therapy together.
What to report, and how soon
| Report | When |
|---|---|
| Thoughts of suicide or self-harm, or a positive answer to PHQ-9 question nine | The same day; if urgent, call or text 988 or go to an emergency room |
| Signs of mania: much less need for sleep, racing thoughts, feeling unusually up, wired or irritable | The same day |
| Clear worsening of depression over several days | Within a day or two |
| Headache or scalp pain that is new, severe or not easing after the first week | At your next session |
| Hearing changes, ringing or ear fullness | At your next session |
| New medications, supplements, poor sleep or heavy drinking | At check-in before treatment |
FDA's guidance for TMS devices asks for a prominent warning about worsening depression or suicidality, so these questions are part of standard monitoring. Treatment-emergent mania with TMS is uncommon, and pooled trials found rates similar to sham. Anyone reporting hearing loss, ringing or ear fullness should be referred for a hearing check.
Getting the most out of a questionnaire
- Answer for the time frame asked. The PHQ-9 asks about the last two weeks, not just today. A single good morning should not erase a hard fortnight, and vice versa.
- Use the same conditions each time. Same day of the week, similar time of day, before rather than after a stressful appointment.
- Do not aim for a score. Underreporting to look like you are improving, or to please the team, makes the numbers useless for decisions about your care.
- Ask to see your trend. A simple line of weekly scores is often more persuasive, to you, than any single number.
- Add context in a sentence. "My father was in hospital this week" explains a spike better than the score alone.
Using your scores at the end of a course
Your final scores, compared with baseline, shape the next step. Clear response or remission leads into a plan for staying well; see building a relapse-prevention plan. A small or no change leads to a different conversation, covered in what to do if TMS does not work. Keep tracking after the course ends, too: a rising PHQ-9 is often the earliest sign that support needs to step up again.
For more on the treatment itself, see the TMS therapy page and the full patient's guide to TMS. Unfamiliar terms are explained in the TMS glossary.
Sources
- The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine, 2001. pmc.ncbi.nlm.nih.gov
- Measurement-Based Care Versus Standard Care for Major Depression: A Randomized Controlled Trial With Blind Raters. American Journal of Psychiatry, 2015. pubmed.ncbi.nlm.nih.gov
- Simultaneous rTMS and psychotherapy in major depressive disorder: Clinical outcomes and predictors from a large naturalistic study. Brain Stimulation, 2018. pubmed.ncbi.nlm.nih.gov
- K231926 510(k) Summary – NeuroStar Advanced Therapy System. U.S. FDA, 2024. accessdata.fda.gov
- Efficacy and safety of deep transcranial magnetic stimulation for major depression: a prospective multicenter randomized controlled trial. World Psychiatry, 2015. pmc.ncbi.nlm.nih.gov
- K220177 510(k) Summary – Magnus Neuromodulation System with SAINT Technology. U.S. FDA, 2022. accessdata.fda.gov
- Transcranial Magnetic Stimulation Retreatment for Recurrent Depression: A Large Real-World Multisite Cohort Study. Acta Psychiatrica Scandinavica, 2026. pubmed.ncbi.nlm.nih.gov
- Transcranial magnetic stimulation (TMS) for major depression: a multisite, naturalistic, observational study of acute treatment outcomes in clinical practice. Depression and Anxiety, 2012. pubmed.ncbi.nlm.nih.gov
- The Effectiveness of Transcranial Magnetic Stimulation in Adolescents and Young Adults With Major Depressive Disorder. JAACAP Open, 2025. pubmed.ncbi.nlm.nih.gov
- Consensus Recommendations for the Clinical Application of Repetitive Transcranial Magnetic Stimulation (rTMS) in the Treatment of Depression. Journal of Clinical Psychiatry, 2018. pmc.ncbi.nlm.nih.gov
- Class II Special Controls Guidance Document: Repetitive Transcranial Magnetic Stimulation (rTMS) Systems. U.S. FDA, 2011. fda.gov
- Hypomanic/manic switch after transcranial magnetic stimulation in mood disorders: A systematic review and meta-analysis. World Journal of Psychiatry, 2021. europepmc.org
- Safety and recommendations for TMS use in healthy subjects and patient populations, with updates on training, ethical and regulatory issues: Expert Guidelines. Clinical Neurophysiology, 2021. europepmc.org
- Treatment-emergent mania in unipolar and bipolar depression: focus on repetitive transcranial magnetic stimulation. International Journal of Neuropsychopharmacology, 2008. europepmc.org
FAQs
How often will I fill out the PHQ-9 during TMS?
It varies by clinic. Weekly is common, and some teams also ask at the start and end of the course. Ask the TMS team what schedule they use and whether you can see your scores.
My score went up this week. Is TMS failing?
Not necessarily. Scores bounce with stress, sleep and life events. Look at the trend over several weeks, and tell the team if the rise is large or lasts more than a few days.
Can I take the PHQ-9 at home?
Yes. It is a free, self-completed questionnaire. Doing it at the same point each week, about the past two weeks, gives the most comparable scores. Share them with your psychiatrist rather than interpreting them alone.
Why do studies report such different success rates?
They use different scales, different definitions of response and remission, and different designs. Clinician-rated, self-reported, sham-controlled and open-label results are not directly comparable.
Should my partner fill out a scale too?
There is no standard partner scale in TMS care, but observations from someone close to you can be useful. Their notes on sleep, activity and mood can sit alongside your own log.
